xià zhī jìng mài xuè shuān xíng chéng
2 English Referencephlebothrombosis of leg
3 Disease CodeICD:I82.8
4 Disease ClassificationCardiovascular Medicine
5 Disease OverviewEmbolism is a disease that occurs when a thrombus or a foreign body is dislodged from the blood stream and becomes blocked at a remote part of the blood flow. Blood flow distal part of the formation of circulatory disorders, this disease in the arterial system is quite common, but in the venous system, the most typical seems to be only the pulmonary artery embolism. In the absence of lower extremity venous embolism, there is no embolic phlebitis of the lower extremities. Deep vein thrombosis occurs in the lower extremities, and its incidence is about 10?times that of the upper extremities.
6 Description of the disease
The more widespread term "lower extremity venous embolism" is a fallacy. Embolism refers to a circulatory obstruction formed by a thrombus or foreign body that has dislodged and migrated to block a part of the blood flow on the distal side of the bloodstream. Although this condition is quite common in the arterial system, the most typical one in the venous system seems to be pulmonary embolism. Neither lower extremity venous embolism, there is no lower extremity embolic phlebitis. Phlebitis caused by thrombosis of the veins of the lower extremities is called thrombophlebitis, and is commonly seen in the superficial veins of the lower extremities, either by intravenous injection of medications, or as a complication of varicose veins of the greater or lesser saphenous veins, or as a concomitant of vasculitis, or as a part of autoimmune disease. Thrombophlebitis of the superficial veins is less likely to cause pulmonary embolism. In contrast, most cases of deep thrombophlebitis are secondary to deep vein thrombosis. The disease is prone to pulmonary embolism and is often associated with surgery, pregnancy, childbirth, prolonged bed rest, and pre-existing obstruction of the inferior vena cava, and in some parts of the country with Bugart's syndrome. Clinically common acute phase for the lower extremity deep vein thrombosis, subacute and chronic phase has become the lower extremity venous thrombosis syndrome, the latter is also very common in the clinic, and focus on the latter.
7 Symptoms and signs1. Primary iliofemoral vein thrombosis? Thrombosis is located in the iliofemoral vein, the incidence than the calf muscle plexus vein thrombosis is low, the left side is more common, for the right side of the 2 to 3?times. In a group of 1,432?cases, the left side accounted for 69.3%, the right side for 26.6%, and 4.1% bilaterally. The iliofemoral vein is the main channel for venous blood return throughout the lower extremities, and once thrombosis occurs, rapid morbidity occurs. The main clinical manifestations of this disease are: ① pain and pressure pain in the affected limb; thrombus-inspired inflammatory reaction can lead to local persistent pain; distal venous blood return obstacles lead to distension and pain, and the symptoms worsen when standing. In the iliofemoral vein, stripes and tenderness can be detected in the course of the vein. Swelling: caused by severe venous return obstruction, so it is generally quite serious. The skin color of the affected limb is purple, and in severe cases, it may be blotchy or even gangrenous. In severe cases, the arterial pulsation of the limb is obviously weakened and disappears. ⑤ Superficial varicose veins are compensatory and not obvious in acute stage. The outcomes of primary iliofemoral vein thrombosis are: ① fibrinolysis and recanalization. ② Limitation and mechanization. ③Thrombus extension: retrograde extension can involve the entire lower extremity deep venous system; collateral extension may violate the inferior vena cava, if the thrombus is dislodged, it can lead to fatal pulmonary embolism.
2. Secondary iliofemoral vein thrombosis? The thrombus originates from the muscular venous plexus of the calf and can involve the entire iliofemoral venous system when it extends downstream. This is called mixed type, which is the most common type in clinical practice. It is characterized by: ① insidious mode of onset; ② symptoms start mild, many patients until the iliofemoral vein involvement, the appearance of typical symptoms were found, so the actual period of illness than the symptomatic period of time; ③ boots area trophic changes, including desquamation, hyperpigmentation, eczema-like changes and ulcers, etc., due to the superficial and deep traffic veins of the lower leg is often originally already diseased, and thus the evolution of the primary type than the much more rapid, and to a greater degree of severity.
3. Phlegmasia?In 1938, Gregoire described a severe diffuse iliofemoral vein thrombosis involving the veins of the entire limb, called phlegmasia (phlegmasia?cerulea), which is not uncommon in clinical practice. This is the most severe type of deep vein thrombosis of the lower extremity, with almost total obstruction of the entire venous system of the lower extremity, including potential collateral branches, a sharp rise in venous pressure, severe pain in the extremity with marked swelling of the entire affected limb, shiny and cyanotic skin, decreased skin temperature, and severe swelling, ischemia, and even necrosis of the affected limb as a result of arteriosclerosis and/or interstitial syndromes. This is called venous or wet gangrene. Shock can result from the entry of large amounts of body fluids into the affected limb in a short period of time and acute limb pain.
8 Etiology of disease1. Blood flow stagnation state? Due to prolonged illness in bed, trauma or fracture, major surgery, pregnancy, childbirth, long-distance car or airplane sedentary, or prolonged sitting and squatting, etc. can make the blood flow slow, stagnation, promote the lower extremity venous thrombosis.
2. High blood coagulation? Such as trauma, post-surgery, extensive burns, pregnancy, postpartum, etc. can make platelets increase, adhesion enhancement, easy to form thrombus.
3. Vein wall damage? Vein wall is affected by any factors, commonly mechanical injury, infectious and chemical injury, will make the collagen in the basement membrane and connective tissue under the endothelium of the vein exposed, platelets then adhered to it, aggregation occurs, and the release of many biologically active substances, such as catecholamines, 5 hydroxytryptophan, etc., and at the same time in the platelets under the action of thrombin, through the formation of arachidonic acid, prostaglandins PGG2, PGH2? and other substances, these substances can in turn aggravate the aggregation of platelets, which is conducive to the formation of thrombus.
4. Other factors? such as age, obesity and anti-activation protein C? and so on.
9 PathophysiologyVirchow (Virchow) in the 20th century put forward the blood flow stagnation, venous wall damage and hypercoagulable state is still the three major factors for the formation of venous thrombosis. However, since then, each factor has either been crystallized or the concept has been updated. Blood stagnation contributes to thrombosis by promoting platelet adhesion, aggregation, and release into the vessel wall. Anatomically, the left iliac vein follows the left iliac artery, making the left iliac vein susceptible to compression and the deep veins of the left lower extremity more susceptible to disease. Injuries to the vein wall include mechanical, chemical (intravenous), infectious and autoimmune diseases. Hypercoagulability of the blood involves infections, tumors, oral contraceptives, decreased antithrombin III activity, C?protein and S?protein abnormalities, and hyperphospholipidemia.
10 Diagnostic testsDiagnosis: In the clinical work of detailed history, careful physical examination, and combined with the necessary auxiliary examination, it is not difficult to make a diagnosis of venous thrombosis of the lower extremities.
Laboratory tests: radioactive fibrinogen test: the application of 125I?-labeled human fibrinogen can be absorbed by the fresh thrombus, so after blocking the thyroid function of iodine uptake, intravenous injection of the agent on the lower limbs of both scans, such as the observation of a sudden increase in the radioactive agent or set of the sudden, it will help to diagnose.
Other ancillary tests:
1. Nuclide venography? Nuclide labeled 99mTc (99mTc) human albumin particles are injected from the dorsal veins of both feet for venography to observe the calf, thigh, pelvic and abdominal veins, and the "hot spots" indicate where the fresh thrombus is located.
2. Doppler flow and volume tracing? This is a non-invasive test that helps to clarify the blood return and blood supply of the affected limbs.
3. Venography? This is a non-invasive test that helps to define the blood return and blood supply of the affected limb. It not only helps to decide the diagnosis, but also helps to directly observe the treatment results. Although this method is the most reliable, when the condition is too serious, it is not necessary to force the completion of this examination. And must take into account the contrast itself may aggravate the lesion, generally in the injection of contrast agent to complete the contrast from the contrast part of the injection of a small amount of heparin, this method helps to prevent the aggravation of the lesion.
4. Measurement of venous pressure? Helps to understand the condition and observe the development. It can be measured alone or at the time of contrast.
11 Differential diagnosisLower extremity venous thrombosis is easily confused with certain lower extremity venous reflux disorders, limb ischemic disease, etc., and clinical attention should be paid to differentiation.
1. Primary lower extremity deep vein valve insufficiency? This disease is due to the lower extremity deep vein valve free edge relaxation, prolapse, valve leaflets can not be close to close, so that the venous blood to the distal end of the limb, causing deep venous hypertension and siltation, and so that the traffic branch venous valves damage, and the lower extremity swelling and obvious superficial varicose veins. It is mostly seen in people who are engaged in standing work for a long time. The onset is insidious and relatively slow. These are not exactly the same as lower extremity venous thrombosis. Be careful to identify.
2. Simple varicose veins of the lower extremities? Mostly seen in young and middle-aged men, mainly characterized by varicose veins of the great saphenous vein and small saphenous vein of the lower limbs. There is a feeling of heaviness and fatigue in the lower limbs, with little swelling, and only after prolonged standing or activity does a slight swelling of the calves and ankles occur, which disappears on its own after rest. While venous thrombosis of the lower limbs, the lower limbs are widely swollen, obviously distended or severe pain, and the secondary superficial venous anger and varicose is also more significant and extensive. If necessary, ultrasound Doppler examination and lower extremity venography, etc., can be clearly diagnosed.
3. Acute arterial embolism of the lower extremities? Most often caused by rheumatic heart disease, coronary artery disease, atrial fibrillation and so on. Sudden onset of severe pain in the limbs, to the fingertips, the affected limbs cold, pale, loss of sensation, limb crumpling, superficial venous atrophy, embolism plane below the arterial pulsation disappeared. Extensive gangrene of the limb may occur. Attention should be paid to the identification.
12 Treatment options1981 to 1986? years, the authors for 15? cases of femoral cyst patients for phlebectomy, intraoperative and postoperative although there is no heavy pulmonary embolism, the results of the treatment is also good, but since 1986? years, the race did not make a case of the same surgery, suggesting that the non-surgical methods of healing is very good for advanced cases before the almost instead of surgery, including the removal of thrombus and interosseous decompression. Acute iliofemoral vein thrombosis, undoubtedly the onset of acute, rapid development, should be applied to the most effective methods. Intravenous heparin, although it can have an immediate anticoagulant effect, thus exerting a thrombolytic effect by mobilizing endogenous cytoplasmic plasminogen, seems to be more passive compared with direct thrombolytic agents. Therefore, the authors have identified fibrinolytic agents as the drug of choice in acute cases. Because of the antigenic nature of streptokinase, intravenous drug is often pyrogenic reaction, thus advocating the use of urokinase. It is commonly used at 100,000 to 200,000 U per day, dissolved in 250 to 500 ml of low molecular dextrose and administered intravenously in 2 doses. It is required to monitor the fibrinogen above 200mg% and the euglobulin time above 80min. Together with the elevation of the affected limbs, the swelling of the affected limbs often subsided significantly within 1 to 3 days. Until the efficacy is obvious or the total amount to 1,000,000 to 2,000,000 U? when the drug is discontinued, changed to intravenous heparin 3 to 5? days, divided into intravenous continuous drip method or divided administration method, the total amount of about 200mg per day to maintain the activation of the coagulation time (ACT) or tube method of coagulation time prolonged by 2 to 3 times. Thereafter, oral anticoagulation (warfarin or vinblastine coumarin tablets) was used for 2 to 3?months to maintain prothrombin activity at 30%? ~?40%? between 30% and 40%. The use of tissue pla *** inogenactivator (TPA) and continuous infusion of fibrinolytic drugs into the lesion through a cephalic microporous catheter may further improve the therapeutic efficacy. Intravenous embolectomy is indicated in cases where the disease progresses rapidly during the course of the above treatments, especially in cases where the beat of the dorsal or posterior tibial arteries decreases dramatically, but it is too late to perform embolectomy in cases where the gangrene is already venous. The main concern with venous thrombectomy is the problem of pulmonary embolism during the procedure. For this reason, it is advisable to place an inferior vena cava filter through the internal jugular vein prior to embolization in order to reliably prevent pulmonary embolism caused by intraoperative dislodgement of the thrombus. The method of inserting a balloon catheter from the femoral vein on the healthy side and blocking it at the bifurcation of the inferior vena cava, which has been described in the literature and used by the authors, is not reliable, because this balloon must be withdrawn after the removal of the embolus, and residual or temporarily blocked thrombus can still be dislodged. Even so, the authors from the affected side of the femoral vein incision with F5? or F6? Fogrty? balloon catheter to remove the embolism, but still make the assistant compression of the abdomen, after the treatment of more than 10? cases, did not see the occurrence of serious pulmonary embolism, but there are 3? cases of postoperative respiratory distress for 1 to 3? days. After the proximal side of the thrombus was removed, the distal side of the femoral vein was blocked by the femoral vein valve, and the Fogarty balloon catheter could not enter in the reverse direction, so the Milking method was used to squeeze the thrombus from the distal side of the blood repellent belt to the proximal side, at which time, it was seen that the thrombus was squeezed out of the femoral vein incision. Incomplete removal of the thrombus from the iliofemoral vein occurs mainly in the left common iliac vein because it may have already been more or less compressed by the left iliac artery, making it difficult to release the local stenosis. Secondly, it is difficult to remove thrombi completely from the middle and small veins of the distal limb. It is natural to keep the patient in a heparinized state before incising the femoral vein. Once the thrombus is removed, either the femoral vein is sutured directly or a temporary distal femoral arteriovenous fistula is added to improve surgical efficacy. Postoperative anticoagulation with heparin via the vein is required for 3 to 5?days before changing to the oral method for 2 to 3?months. Once the femoral bruise has progressed to the necrotic stage, only a wide intermuscular dissection is done to allow adequate drainage of the necrotic tissue. Elevation of the affected limb and frequent dressing changes may be the only treatment. The authors, with nearly 1?year, have cured 1?example of this severe case. Failure to achieve relief in the acute phase results in the development of post-thrombotic syndrome of the lower extremity veins.
13 ComplicationsThromboembolism (pulmonary embolism, cerebral embolism, etc.); chronic ulceration of the lower extremities, etc., and in severe cases, acute pulmonary embolism leading to sudden death can occur.
14 Prognosis and preventionPrognosis: It is generally recognized that acute deep vein thrombosis enters the sequelae period after 3 to 6?months. DVT undergoes resorption and polarization, as well as a slow process of recanalization, the more proximally located the thrombosis, the less likely it is to recanalize. According to Dale?s report, the recanalization rate of iliofemoral vein thrombosis is about 1% to 2%. In addition, thrombus in the process of recanalization, the valve can be destroyed, and reflux lesions. Lower limbs in addition to the obvious limb swelling, due to long-term deep venous return obstacles, calf deep venous hypertension, more involved in the traffic branch so that the lower limbs of the superficial varicose veins is more pronounced, boot area can be due to skin nutritional disorders appear chronic eczema, hyperpigmentation, and even stasis ulcers.
Prevention:
1. Mechanical methods? Designed to promote venous return of the lower extremities. With electric *** instrument *** gastrocnemius muscle, to circulatory drive or rhythmic positive or negative pressure driver can effectively promote limb circulation. Encourage early ankle and quadriceps mobilization, deep breathing and coughing, and getting out of bed as early as possible are equally important. After surgery, wear medical compression stockings with pressure difference, such as calf 4.0kPa (30mmHg), thigh 2.67kPa (20mmHg) pressure also play a role in driving the circulation.
2. Drug prophylaxis? The first is small-dose subcutaneous heparin therapy. Comprehensive data show that subcutaneous heparin therapy reduces the incidence of postoperative deep vein thrombosis from 25% to 7%; the incidence of large pulmonary embolism from 6% to 0.6%. The mechanism by which small doses of heparin exert their prophylactic effect is not fully understood. The subcutaneous route slows the absorption of the drug, allowing the body to maintain a certain heparin concentration more consistently may be the main reason. Use is usually by subcutaneous injection of 50 mg 2 h?before surgery and 50 mg every 12?hours?thereafter.Antiplatelet therapy consists mainly of enteric-coated aspirin and dipyridamole. The role of low molecular dextran is to reduce the viscosity of the blood, and can be injected intravenously 500 to 1000 ml per day as appropriate.
15 EpidemiologyDeep venous thrombosis occurs in the lower limbs, and its incidence is about 10 times that of the upper limbs. At present, there is no precise statistical data on the incidence of DVT in China, but the trend is increasing year by year.
16 Special tipsEncourage the patient to do ankle and quadriceps activities early after surgery, and do more deep breathing and coughing, and get out of bed as soon as possible is equally important. After surgery, wear medical compression stockings with pressure difference, such as calf 4.0kPa (30mmHg), thigh 2.67kPa (20mmHg) pressure also play a role in circulation drive.
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